APPEALS RESOLUTION OFFICER DECISION
Decision Number: 20240033
OBJECTING PARTY: worker
REPRESENTED by: WORKER REPRESENTATIVE
RESPONDENT: employer
REPRESENTED by: EMPLOYER REPRESENTATIVE
HEARING: HEARING IN WRITING
HEARD by: c. goegan, appeals resolution officer
ISSUES
The worker is objecting to the following decisions of the Case Manager:
The October 18, 2022, decision denying entitlement to the diagnosis of post-traumatic stress disorder (PTSD).
The August 8, 2023, decision denying entitlement to post-traumatic vision syndrome.
BACKGROUND
On November 22, 2018, a special needs student grabbed this then 24-year-old educational assistant by the hair and forcefully head butted the left side of the worker’s forehead multiple times. The worker stopped working the following day and reported the injury to the employer. They sought medical attention and were diagnosed with a concussion (mild traumatic brain injury – MTBI). The Operating Area approved the claim for health care and loss of earnings (LOE) benefits on November 27, 2018.
The worker initially returned to modified duties at less than regular hours in January 2019. They received periods of partial and full LOE benefits during 2019, treatment for the MTBI, and attended multiple assessments at a WSIB Neurology Specialty Clinic. The worker stopped working on October 22, 2019, and the clinicians at the Specialty Clinic recommended they remain off work because of the MTBI. The Case Manger accepted the findings of the Specialty Clinic assessors and approved the payment of full LOE benefits. In addition to the MTBI, the Case Manager accepted the worker injured their neck in the accident and extended entitlement in the claim for a neck injury.
The worker was ultimately determined to have reached maximum medical recovery for the MTBI by October 20, 2020. The Case Manager determined the injury resulted in a permanent impairment and the worker later received a 5% Non-Economic Loss (NEL) benefit for the MTBI.
The worker also experienced psychological symptoms. They attended a psychiatric assessment at the Neurology Specialty Clinic in July 2021 and the psychiatrist that completed the evaluation recommended the worker receive treatment through the Community Mental Health Program (CMHP). Following the Specialty Clinic assessment, The Case Manager approved temporary entitlement to a generalized anxiety disorder and major depressive disorder in a decision dated September 17, 2021.
The worker attended psychological treatment through the CMHP. The Operating Area referred the worker for a comprehensive assessment at a WSIB Mental Health Specialty Clinic, and the assessment took place on June 20, 2022. Upon completing the assessment, the clinicians at the Specialty Clinic diagnosed the worker with major depressive disorder and PTSD. In a decision dated October 18, 2022, the Case Manager denied entitlement to the diagnosis of PTSD as they determined the accident was not objectively traumatic.
On November 17, 2022, the Case Manager concluded the worker reached maximum medical recovery for the major depressive disorder with a permanent impairment. The Case Manager also determined the neck injury and the generalized anxiety disorder resolved. They found that any ongoing symptoms related to post-traumatic vision syndrome had been recognized by the 5% NEL award for the MTBI, and concluded the worker was able to return to suitable work.
A NEL Clinical Specialist subsequently calculated the NEL rating for the psychological impairment at 20%. The NEL Clinical Specialist combined (not added) the 20% NEL rating for the psychological impairment with the previously determined 5% NEL rating for the MTBI and the total amount of the whole person NEL award increased to 24%.
In a decision dated January 19, 2023, the Nurse Consultant denied entitlement to any further treatment for the MTBI or the psychological condition on the basis the worker had previously reached maximum medical recovery for both impairments.
The Operating Area concluded the pre-injury job of educational assistant was no longer suitable. The employer offered the worker a temporary alternate administrative position and the worker returned to work in April 2023.
The worker representative requested funding for a vision assessment and treatment. The Nurse Consultant denied the request on March 7, 2023, on the basis the worker did not have entitlement to vision issues. In a decision dated August 8, 2023, the Case Manager denied entitlement to post-traumatic vision syndrome as they concluded the diagnosis was not compatible with the accident as it was not endorsed by the assessors at the WSIB Neurology Specialty Clinic.
The worker, through their representative, objected to the October 18, 2022, and the August 8, 2023, decisions of the Case Manager and the matter was referred to the Appeals Services Division for consideration.
AUTHORITY
Operational Policy Manual
Published
11-01-01 – Adjudicative Process 15-04-02 – Psychotraumatic Disability 15-03-02 – Traumatic Mental Stress
November 3, 2008 September 7, 2018 January 2, 2018
Reference:
The American Medical Association’s Guides to the Evaluation of Permanent Impairment, 3rd.edition revised, (AMA Guides).
ANALYSIS
I carefully considered all the available information, legislation, and relevant operational policies in reaching this decision. For the reasons explained below, I find:
The worker has entitlement to the diagnosis of PTSD.
The worker does not have entitlement to post-traumatic vision syndrome as an organic disorder of the visual system.
The Worker’s Position
The worker representative provided submissions with the December 4, 2023, Appeal Readiness Form.
I reviewed and considered the submissions in their entirety; however, I have summarized the representative’s arguments and positions as follows:
The worker was previously granted entitlement to a psychotraumatic disability under the criteria in Policy 15-04-02 (Psychotraumatic Disability) and has received a NEL award for a permanent psychological impairment. The representative argued there is no stipulation in the policy excluding specific psychological diagnoses, or any requirement that an accident which contributes significantly to the development of a psychotraumatic disability must be objectively traumatic.
The representative submitted Policy 15-04-02 (Psychotraumatic Disability) clearly confirms a worker is entitled to benefits for a psychotraumatic disability when the compensable accident and/or the resultant injury contributes in a significant way to a diagnosed psychological condition. It is not necessary to quantify and qualify the severity of the accident.
There is no evidence suggesting the worker had pre-existing PTSD or was immediate risk for the development of PTSD before the accident.
The representative argued significant weight should be placed on the diagnostic opinions of the assessors at the WSIB Mental Health Specialty Clinic. She submitted their opinion is supported by clinical evidence in the record from other health care professions that examined and treated the worker for the psychological condition. The representative submitted that as the Specialty Clinic assessors conclude there was a causal relationship between the accident and the PTSD, the worker’s entitlement should include that psychological condition.
The representative argued that while the Operating Area accepted the worker experienced vision issues as the sequelae of the MTBI, they did not accept the diagnosis of post-traumatic vision syndrome. She argued that as the diagnosis was rendered by an optometrist, separate entitlement should be granted for that condition, including a NEL evaluation under chapter 8 of the AMA Guides.
The Employer’s Position
The employer representative also made submissions with the March 19, 2024, Respondent Form. I also reviewed the submissions in their entirely and summarized them as follows:
The accident history of being grabbed by the hair by a special needs student and being head butted is not an objectively traumatic accident as defined in Policy 15-03-02 (Traumatic Mental Stress). The representative submitted the worker is a trained educational assistant and would have been accustomed to working with students with special needs.
The representative submitted the PTSD did not indirectly result from the accident or injury, a severe physical disability or impairment, nor was it a reaction to the treatment process. She argued the worker does not meet the criteria for entitlement to PTSD under Policy 15-04-02 (Psychotraumatic Disability).
With respect to post-traumatic vision syndrome, the employer representative submitted the reporting from the assessors at the WSIB Neurology Specialty Clinic should be afforded the most weight. She argued that the Specialty Clinic assessors concluded an examination of the worker’s vision was normal and opined their ongoing symptoms were predominantly psychiatric. As such, the representative argued the decision to deny post-traumatic vision syndrome was appropriate.
Entitlement to Post-Traumatic Stress Disorder (PTSD)
Policy 15-04-02 (Psychotraumatic Disability) states that a worker is entitled to benefits when an impairment results from a work-related injury that is caused by an accident. Impairment includes both physical and psychological conditions.
The policy provides that if a psychological condition is attributable to a work-related injury or a condition resulting from a work-related injury, entitlement is granted providing the psychotraumatic disability developed within five years of the injury or the last surgical procedure. A psychotraumatic disability is considered to be a temporary condition and is accepted as permanent only in exceptional circumstances.
The policy states that entitlement for any psychotraumatic disability may be established when the following circumstances exist or develop:
- Organic brain syndrome secondary to
o Traumatic head injury
o Toxic chemicals including gases.
o Hypoxic conditions, or
o Conditions related to decompression sickness.
- An indirect result of a physical injury
o Emotional reaction to the accident or injury
o Severe physical disability or impairment, or
o Reaction to the treatment process.
- The psychotraumatic disability is shown to be related to extended disablement and to non-medical, socioeconomic factors, the majority of which can be directly and clearly related to the work-related injury.
The Operating Area previously concluded the worker developed psychological symptoms within five-years of the accident and met at least one of the requisite criteria required for entitlement under Policy 15-02-02 (Psychotraumatic Disability) when they granted temporary entitlement to the psychotraumatic disability in the claim. The Case Manager subsequently concluded the circumstances in the case were exceptional and accepted the worker’s psychological impairment was permanent. The worker is presently in receipt of a 20% NEL award for a psychotraumatic disability.
Noting the above, I will begin by confirming that the issue of whether the worker has initial entitlement to benefits for a psychotraumatic disability is not before me in this appeal. The only issue properly before me is whether the psychotraumatic disability should include the diagnosis of PTSD.
After considering the evidence in the record and the submissions of the respective representatives, I find the worker has entitlement to the diagnosis of PTSD. In reaching that conclusion, I found the following information most relevant:
A December 3, 2020, Neurology Specialty Clinic Psychiatry Assessment Report from Dr. Razmy had the occupational diagnoses of generalized anxiety disorder and major depressive disorder. The report stated the worker denied any symptoms of PTSD.
Dr. Razmy re-evaluated the worker on July 23, 2021. He suggested the worker remain off work and made treatment and medication recommendations. The report continued to state the worker denied any symptoms of PTSD.
A September 17, 2021, CMHP report from Dr. Sanghera, a psychologist, indicated she administered a screening tool to assess for mental stress. Dr. Sanghera noted that while the worker reported symptoms typically related to trauma, she considered the symptoms to be related to anxiety and mood, and therefore found they were not clinically significant. However, she listed symptoms of trauma as an occupational diagnosis in the report.
The worker continued attending treatment in the CMHP with Dr. Harris, a psychologist and his reports continued to list symptoms of trauma related to workplace injury as a diagnosis.
On June 20, 2022, the worker attended a comprehensive assessment at a WSIB Mental Health Specialty Clinic. Dr. Muller, a psychiatrist, and Dr. Kamkar, a psychologist, completed the evaluation. In the report that followed the assessment, the assessors endorsed the occupational diagnoses of PTSD and major depressive disorder. They indicated the symptoms of PTSD started following the index accident and opined they were directly attributable in onset to the index event.
A January 5, 2023, letter from Dr. Hooper, the worker’s family doctor indicated the worker had developed PTSD from the accident and continued to struggle with symptoms.
CMHP reports from Dr. Harris June 20, 2022, and May 30, 2023, continued to list the occupational diagnoses of major depressive disorder and PTSD provided by Dr. Muller and Dr. Kamkar.
Although Dr. Razmy is a psychiatrist at the Neurology Specialty Clinic and his reports stated the worker denied symptoms of PTSD, the CMHP reports from Dr. Sanghera and Dr. Harris consistently listed symptoms of trauma as an occupational diagnosis. Despite the differences between Dr. Razmy’s reports and the CMHP reports, I placed more weight on the June 20, 2022, Specialty Clinic report from Dr. Mueller and Dr. Kamkar than I did on the other reports for several reasons.
First, Dr. Mueller and Dr. Kamkar completed a multi-disciplinary assessment at the Mental Health Specialty Clinic that included specific screening for multiple psychiatric disorders (including trauma and stressor-related disorders). Second, Dr. Mueller and Dr. Kamkar are expert assessors that were specifically tasked by the Operating Area with evaluating the worker’s psychological presentation and confirming any diagnoses that were related to the accident or the physical injury. Finally, I find their report is detailed and the reasons they formulated their combined diagnostic opinions that PTSD was an occupational diagnosis are thoroughly explained. Since I place the most weight on the combined opinions of Dr. Mueller and Dr. Kamkar, I accept the worker developed PTSD as a direct result of the accident and I conclude the psychotraumatic disability includes that diagnosis.
The worker representative has correctly pointed out that Policy 15-04-02 (Psychotraumatic Disability) does not contain any specific provision specifying that certain diagnostic requirements must be met, or that an accident or injury that gives rise to a psychological impairment must be objectively traumatic in nature, to qualify for benefits under the policy. The only requirements in the policy are that the psychological impairment manifests within five years of the accident and there is a relationship between the impairment and the accident or injury. In this regard, the worker was diagnosed with PTSD within five years of the compensable injury, and as noted above, I accept there is a direct relationship between that diagnosis and the accident.
Independent of Policy 15-04-02 (Psychotraumatic Disability), the employer representative submitted the accident was not objectively traumatic pursuant to Policy 15-03-02 (Traumatic Mental Stress) because they were trained and accustomed to working with special needs children. Although I find the worker has entitlement to PTSD under Policy 15-04-02 (Psychotraumatic Disability) and an objectively traumatic event is not required, I respectfully disagree that the accident was not objectively traumatic in nature. Policy 15-03-02 (Traumatic Mental Stress) contains a list of examples of objectively traumatic events and one such is example is being the object of physical violence. In my view, being grabbed by the hair and forcefully struck in the head more than once is objectively traumatic in nature, regardless of whether the worker was an educational assistant and accustomed to working with special needs children.
In summary, I conclude there is a relationship between the diagnosis of PTSD and the accident. Accordingly, I find the worker has entitlement to the diagnosis of PTSD.
Entitlement to Post-Traumatic Vision Syndrome
Policy 11-01-01 (Adjudicative Process) contains a five-point check system that is required to establish entitlement to a claim for compensation. The fifth point in the system is compatibility between a diagnosis and the accident history.
The worker representative submitted that significant weight should be afforded to a December 2, 2020, report from Dr. Tai, an optometrist. She argued the worker should receive a permanent impairment rating for post-traumatic vision syndrome under Chapter 8 of the AMA Guides because the accident contributed significantly to that diagnosis.
Given the evidence before me, however, I find the worker does not have entitlement to post-traumatic vision syndrome as an organic disorder of the visual system. In reaching that conclusion, I took note of the following:
There is no contemporaneous evidence suggesting that the worker sustained an external or internal eye injury in the accident.
An October 18, 2019, Neurology Specialty Clinic report from Dr. Grewal, a neurologist, indicated the worker’s extraocular movements were normal, including convergence. He also reported a cranial nerve examination was normal.
A November 1, 2019, Specialty Clinic report from Dr. Desai, a neurologist indicated that during a previous neurological assessment the worker’s pupils were symmetric and reactive to light, both directionally and consensually. Dr. Desai also reported extraocular eye movements were full, a fundoscopic examination (an examination of the retina) was normal and there was no evidence of papilledema (swelling of the optic discs due to increased intracranial pressure).
A Specialty Clinic report dated October 5, 2020, from neurologist Dr. Ghavanini, indicated the worker reported visual symptoms that included intermittent blurred vision in the left eye with bending and poor sleep. He noted the worker was waiting to start optometric treatment with
Dr. Tai even though there were no overt visual disturbances. On examination, Dr. Ghavanini indicated the worker’s pupils were equal and reactive to light. The visual fields were normal and extraocular movements showed normal pursuit and range. There was no nystagmus (repetitive, uncontrolled eye movements), and no double vision. He indicated that while post-concussion syndrome could not be ruled out, the majority of the worker’s symptoms were functional and related to a psychiatric disorder.
The December 2, 2020, report from Dr. Tai described a multitude of vision symptoms. Dr. Tai completed an examination and reported the internal and external examination of the eyes revealed normal ocular health. He also reported the worker’s visual acuity was within normal limits. Dr. Tai endorsed multiple diagnoses that included accommodative dysfunction, convergency insufficiency, oculo-motor dysfunction, central-peripheral awareness dysfunction, poor sensory fusion, vergence fusional dysfunction and visual information processing dysfunction.
A February 12, 2021, MRI of the brain performed for left eye visual abnormalities stated there were minimal white matter hyperintensities in the left and right parietal and occipital lobes, which were non-specific.
In submissions, the worker representative argued the worker has a visual impairment that should attract a separate permanent impairment rating independent of the NEL rating for the MTBI. While I make no findings on the NEL rating for the MTBI, I do not find the representative’s argument persuasive.
According to the AMA Guides, organic lesions involving the optic nerve, chiasm, tracts, radiations, or visual cortex may result in disturbances in the visual fields. Organic lesions involving any of those structures are evaluated under Chapter 8 (The Visual System) in the AMA Guides. To attract an impairment rating under Chapter 8, there must be an organic basis for central vision loss, visual field loss and the loss of ocular motility (eye movement).
I find the evidence does not establish the worker has an organic impairment of the visual system.
The worker was examined by three different neurologists at the WSIB Specialty Clinic. None of their reports describe an organic basis for a visual system impairment. The neurologist’ s reports describe visual system examinations, including examinations of the cranial nerves responsible for ocular motility and there were no references to an organic based visual disorder in the reports. In addition to the normal neurologic findings reported by the Specialty Clinic assessors, the MRI of the brain did not describe a specific finding of an organic injury to the visual cortex in the occipital lobe of the brain.
I have placed weight on the Specialty Clinic reports. The reports were authored by three different neurologists, and all three reports contain similar examination findings, which do not support that there is an organic basis for an accident-related visual system impairment.
I acknowledge the report of Dr. Tai, but I afforded it less weight in reaching my conclusion.
Dr. Tai, who is an optometrist and not a neurologist, confirmed the worker had normal ocular health and normal vision. Therefore, there is no basis to consider an impairment of the central vision or the visual fields under Chapter 8 of the AMA Guides. While Dr. Tai endorsed multiple diagnoses that relate to ocular motility, I find his opinion is outweighed by the multiple Specialty Clinic reports describing normal eye movement as well as the non-specific MRI results. Accordingly, I conclude the worker does not have entitlement to post-traumatic vision syndrome as an organic disorder of the visual system.
CONCLUSION
I conclude the following:
The worker has entitlement to the diagnosis of PTSD.
The worker does not have entitlement to post-traumatic vision syndrome as an organic disorder of the visual system.
The worker’s objection is allowed in part.
DATED April 23, 2024
C. Goegan Appeals Resolution Officer Appeals Services Division